State insurance mandates and off‐label use of chemotherapy

Access to cancer drugs used off‐label is important to cancer patients but may drive up healthcare costs with little evidence of clinical benefit. We hypothesized that state health insurance mandates for private insurers to provide coverage for off‐label use of cancer drugs cause higher rates of off‐label use. We used Truven MarketScan data from 1999 to 2007 on utilization of 35 infused chemotherapy drugs in private health plans in the United States, covering the period when eight states implemented off‐label coverage laws. We studied trends in off‐label use of drugs, distinguishing between appropriate and inappropriate off‐label use according to drug compendia, and estimated difference‐in‐difference regressions of the effect of state laws on off‐label use. We estimate 41% of utilization was off‐label, including 17% of use conservatively defined as inappropriate. Trends show gradual declines in off‐label use over time. We also find no discernable effect of state laws mandating coverage of off‐label use of cancer drugs on utilization patterns under multiple empirical specifications. Our conclusion is that policymakers should consider shifting away from mandating coverage as a way to ensure access to drugs off‐label and towards incentivizing adherence to clinical practice guidelines to improve the quality and value of off‐label use.     

Spigelian hernia presenting as an appendicular mass

Incarcerated spigelian hernias are a rare cause of acute abdomen. The clinical diagnosis of incarcerated spigelian hernia can be a challenge in the absence of definite signs. Reported here is a case of a strangulated spigelian hernia that mimicked an appendicular mass and was discovered on CT scan of the abdomen and pelvis.     

FDC:TFH Interactions within Cervical Lymph Nodes of SIV-Infected Rhesus Macaques

Cerebrospinal fluid (CSF) drains via the lymphatic drainage pathway. This lymphatic pathway connects the central nervous system (CNS) to the cervical lymph node (CLN). As the CSF drains to CLN via the dural and nasal lymphatics, T cells and antigen presenting cells pass along the channels from the subarachnoid space through the cribriform plate. Human immunodeficiency virus (HIV) may also egress from the CNS along this pathway. As a result, HIV egressing from the CNS may accumulate within the CLN. Towards this objective, we analyzed CLNs isolated from rhesus macaques that were chronically-infected with simian immunodeficiency virus (SIV). We detected significant accumulation of SIV within the CLNs. SIV virion trapping was observed on follicular dendritic cells (FDCs) localized within the follicular regions of CLNs. In addition, SIV antigens formed immune complexes when FDCs interacted with B cells within the germinal centers. Subsequent interaction of these B cells with CD4+ T follicular helper cells (T_FHs) resulted in infection of the latter. Of note, 73% to 90% of the T_FHs cells within CLNs were positive for SIV p27 antigen. As such, it appears that not only do the FDCs retain SIV they also transmit them (via B cells) to T_FHs within these CLNs. This interaction results in infection of T_FHs in the CLNs. Based on these observations, we infer that FDCs within the CLNs have a novel role in SIV entrapment with implications for viral trafficking.     

Determining replacement teeth position for the implant-retained prosthesis in the edentulous patient

A pleasing final appearance is vitally important for patients who undergo extensive oral rehabilitation. This applies equally to the fields of orthodontics, restorative, prosthetic, and implant dentistry. In the field of removable prostheses there are biometric guides that aid in the replacement of teeth especially when the anatomical ridges are severely resorbed. These guides should be considered when planning the appearance and function of prostheses. This paper suggests that in view of the fact that unfavourable placement of implant fixtures is not easily rectified, knowledge of biometric guides can be critical in the treatment planning of the implant supported prosthesis especially when there are large resorbed edentulous spans.     

Dorsal approach for double-face bulbar urethroplasty: ventral inlay plus dorsal onlay using Kulkarni one-side dissection

International Urology and Nephrology - Non-traumatic obliterative bulbar urethral stricture with residual urethral lumen below 3 Fr is a challenging surgical scenario for reconstructive...     

The impact of head and neck radiation on airway management: a retrospective data review

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -